Hysterectomy is routinely performed in a potentially contaminated field due to the inability to completely sterilize the vagina. After removal of the uterus in either abdominal or vaginal hysterectomies, serum and blood collect in the retroperitoneal space. To lower the incidence of infection, most gynecologic surgeons insert a drain tube in this space, typically a Jackson-Pratt drain tube, to drain this fluid for about 72 hours after surgery. The tube is then removed by pulling the tube through the vagina. The Jackson-Pratt tube is in the form of a soft flexible T having a short top arm with drain holes and a long leg extending through the vagina, the end of which is connected to a drain pump.
Though effective in removing fluid from the retroperitoneal space, the Jackson-Pratt drain tube is difficult to insert and can cause irritation to sensitive tissue in the retroperitoneal space and the walls of the vagina, especially with older patients. Though the vaginal cuff differs from patient to patient, the Jackson-Pratt drain tube has a fixed geometry. If the upper arm is too short it can slip into the vaginal cuff. If it is too long, it can irritate tissue that it contacts. If the ends of the arms are trimmed, the sharp edges can irritate the vaginal walls when the drain tube is removed by pulling it through the vagina.
The drain holes are not uniformly spaced in the Jackson-Pratt drain and the device does not readily collapse when pulled, resulting in a Y-shaped configuration with the arms rubbing against the vaginal wall. Some of the drain holes on the lower surface of the arms are now disposed to the outside facing the vaginal wall and cause abrasion and irritation during removal.
The most serious problem is the difficulty in inserting the drain tube through the vagina. The surgery takes place in a sterile field. The vagina is a relatively collapsed tube with a soft curve running in a cephalo distal plane. The soft flexible tube must be pushed through collapsed tissue having a curved path. A further complexity is presented by the presence of an almost identical tube in shape and feel. During hysterectomy surgery a Foley catheter is passed through the uterus to drain fluid from the bladder of the patient.
The nurse must use a forceps to force the long leg of the drain tube through the vaginal cuff and far enough into the vagina to grasp the tip of the tube with her other gloved hand. This is very confusing to the nurse as she is extracting the long leg of the Jackson-Pratt drain by feel only and is unable to view the drain. The sharp end of the tube and the forceps can and do irritate tissue. The sterile field is violated with the glove and the forceps. The gloved hand working in the collapsed vagina does not have sensitive tactile feeling and it is common to mistake the similarly-sized Foley catheter for the Jackson-Pratt drain tube resulting in draining the bladder.